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Iliopectineal Ligament As an Important Landmark in Ilioinguinal Approach of the Anterior Acetabulum

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International Journal of Anatomy and Research, Int J Anat Res 2019, Vol 7(3.3):6976-82. ISSN 2321-4287 Original Research Article DOI: https://dx.doi.org/10.16965/ijar.2019.274 ILIOPECTINEAL LIGAMENT AS AN IMPORTANT LANDMARK IN ILIOINGUINAL APPROACH OF THE ANTERIOR ACETABULUM: A CADAVERIC MORPHOLOGIC STUDY Ayman Ahmed Khanfour *1, Ashraf Ahmed Khanfour 2. *1 Anatomy department Faculty of Medicine, Alexandria University, Egypt. 2 Chairman of Orthopaedic surgery department Damanhour National Medical Institute Egypt. ABSTRACT Background: The iliopectineal ligament is the most stout anterior part of the iliopectineal membrane. It separates “lacuna musculorum” laterally from “lacuna vasorum” medially. This ligament is an important guide in the safe anterior approach to the acetabulum. Aim of the work: To study the detailed anatomy of the iliopectineal ligament demonstrating its importance as a surgical landmark in the anterior approach to the acetabulum. Material and methods: The material of this work included eight adult formalin preserved cadavers. Dissection of the groin was done for each cadaver in supine position with exposure of the inguinal ligament. The iliopectineal ligament and the three surgical windows in the anterior approach to the acetabulum were revealed. Results: Results described the detailed morphological anatomy of the iliopectineal ligament as regard its thickness, attachments and variations in its thickness. The study also revealed important anatomical measurements in relation to the inguinal ligament. The distance between the anterior superior iliac spine (ASIS) to the pubic tubercle ranged from 6.7 to 10.1 cm with a mean value of 8.31±1.3. The distance between the anterior superior iliac spine (ASIS) to the blending point of the iliopectineal ligament to the inguinal ligament ranged from 1.55 to 1.92 cm with a mean value of 1.78±0.15. Conclusion: The iliopectineal ligament detailed morphology and attachments are crucial when planning to do anterior approach of the acetabulum to decrease incidence of iatrogenic injury to the femoral vessels. KEY WORDS: Iliopsoas fascia - Iliopectineal membrane - Iliopectineal ligament - Inguinal ligament -Anterior acetabular approach. Address for Correspondence: Ayman Ahmed Khanfour: Assistant professor in the human Anatomy and Embryology department, Faculty of Medicine, University of Alexandria, Egypt. Mobile: 00201223815866. E-Mail: [email protected] Access this Article online Journal Information Quick Response code International Journal of Anatomy and Research ICV for 2016 ISSN (E) 2321-4287 | ISSN (P) 2321-8967 90.30 https://www.ijmhr.org/ijar.htm DOI-Prefix: https://dx.doi.org/10.16965/ijar Article Information Received: 17 Jul 2019 Accepted: 19 Aug 2019 Peer Review: 17 Jul 2019 Published (O): 05 Sep 2019 DOI: 10.16965/ijar.2019.274 Revised: None Published (P): 05 Sep 2019 INTRODUCTION considered as a continuation of the transversus The iliopsoas fascia is the mother name given abdominis fascia. It is thinner anteriorly but to all the relatively dense layer of fascia that progressively becomes thicker medially [1,2]. covers the anteromedial aspect of iliopsoas The iliopectineal membrane is the relatively muscle as a whole. It tethers the iliopsoas denser medial part of this iliopsoas fascia on muscle, femoral nerve and lateral cutaneous its anteromedial surface run the great femoral nerve of the thigh to the iliac fossa. It could be vessels. Consequently, the most anterior part of Int J Anat Res 2019, 7(3.3):6976-82. ISSN 2321-4287 6976 Ayman Ahmed Khanfour, Ashraf Ahmed Khanfour. ILIOPECTINEAL LIGAMENT AS AN IMPORTANT LANDMARK IN ILIOINGUINAL APPROACH OF THE ANTERIOR ACETABULUM: A CADAVERIC MORPHOLOGIC STUDY. this iliopectineal membrane forms an even more (Fig. 1). The skin and subcutaneous tissues along stout ligament like structure that is called the the proposed line of incision were deepened up iliopectineal ligament which subdivides the to the aponeurosis of the external oblique space deep to the inguinal ligament into a muscle. At the end, the ilioinguinal approach was lateral muscular lacunae and a medial vascular completed by developing three anatomical lacunae [3]. windows (Fig. 2). The 1st window was devel- Surgical treatment of anterior acetabular oped by subperiosteal dissection of the iliac fractures entails good anatomic reduction with crest and iliac fossa elevating the insertion of restoring hip congruency [4,5]. This necessi- the anterior abdominal wall muscles together tates adequate anterior exposure using the well- with the origin of the iliacus in continuity up to known ilioinguinal approach in which isolation the sacroiliac joint posteriorly and the pelvic of the iliopectineal ligament is a crucial step [6]. brim anteriorly. The 2nd window starts by opening the anterior wall of the inguinal canal Sharp cutting of this iliopectineal ligament as a by incising the external oblique aponeurosis crucial step in the ilioinguinal approach to from the anterior superior iliac spine (ASIS) up mobilize the iliopsoas muscle to permit good to the midline 1 cm above the superficial exposure, reduction and fixation of anterior inguinal ring. The spermatic cord or the round acetabular fractures located anyway from the ligament was retracted by a rubber sling anterior aspect of the sacroiliac joint up to the medially. pubic symphysis, including exposure of the quadrilateral surface. Unfortunately, great Then, the posterior wall of the inguinal canal is femoral vessels (artery and vein) lie directly on opened by sharp incising the inguinal ligament the anteromedial surface of this ligament, into two equal superior and inferior flaps, putting them at high risk for iatrogenic injury exposing the subinguinal region posterior to the [7,8]. Limited sources about the detailed inguinal ligament. This region is subdivided into morphological anatomy about this important two spaces; the “lacuna vasorum” lies medially iliopectineal membrane and ligament was the and the “lacuna musculosum” laterally major driving force for this study. separated by the iliopectineal ligament that is the issue of this study. Now the 2nd window can Aim of the work: The aim of this work was to be developed by retracting the “lacuna study the detailed anatomy of the iliopectineal musculosum” containing the iliopsoas, the ligament demonstrating its importance as a femoral nerve and the lateral cutaneous nerve surgical landmark in the anterior approach to of the thigh laterally, and the “Lacuna vasorum” the acetabulum. And using it together with spe- containing the external iliac vessels medially cial surgical tactics to prevent iatrogenic injury with the iliopectineal ligament. At this stage, to great femoral vessels. the iliopectineal membrane and ligament MATERIALS AND METHODS become fully isolated and their detailed The material of this work included eight adult anatomical morphology was studied as regards formalin preserved cadavers obtained from the their attachment, thickness, point of its hitch Dissecting Room of Anatomy Department, hike of the iliopectineal ligament to the inguinal Faculty of Medicine, Alexandria University. ligament, and their relation to the vital In this study, the ilioinguinal approach that was structures especially great femoral vessels. In originally described in the literature of Emile the original description of this approach, the Letournel in 1993 was simulated in all of the iliopectineal ligament and membrane were cases included in this study [7]. The cadaveric completely incised in an anteroposterior position was supine with exposure of the groin direction up to the pelvic brim in order to freely area. An incision was done extending along the mobilize the Iliopsoas muscle developing the 3rd anterior two-thirds of the iliac crest, passing window by retracting the slung lacuna vasorum through the anterior superior iliac spine (ASIS) laterally and the spermatic cord medially. At this then continued to the midline, approximately step, a detailed morphological anatomy of the two fingerbreadths above the pubic symphysis iliopectineal membrane and ligament took place. Int J Anat Res 2019, 7(3.3):6976-82. ISSN 2321-4287 6977 Ayman Ahmed Khanfour, Ashraf Ahmed Khanfour. ILIOPECTINEAL LIGAMENT AS AN IMPORTANT LANDMARK IN ILIOINGUINAL APPROACH OF THE ANTERIOR ACETABULUM: A CADAVERIC MORPHOLOGIC STUDY. Fig. 1: A photograph of a right side groin showing the analysis was done using Statistical Package for line of incision starting from the anterior two-thirds of Social Sciences (SPSS/version 20) software. the iliac crest (I), passing through the anterior superior iliac spine (ASIS) then continues to the midline, approxi- Arthematic mean, standard deviation were used mately two fingerbreadths above the pubic symphysis to the numerical measurements. To find the (SP). association between two variables, Spearman correlation coefficient test was used and the level of significant was 0.05. To predict the distance of the blending point of iliopectineal ligament to inguinal ligament, the multiple logestic regression analysis was done to predict the equation. RESULTS Morphological findings: The investing fascia of the iliopsoas was found to invest the iliop- soas muscle together with the femoral nerve and the lateral cutaneous nerve of the thigh. It forms a thin membrane anteriorly, then it becomes thicker as we go medially to form the iliopectineal membrane. Again, the most anterior part of the iliopectineal membrane Fig. 2: A photograph of a right groin showing the three becomes
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